Abnormal Cervical Smear Results

Cervical screening has prevented an epidemic that would have killed about one in 65 of all British women born since 1950 and culminated in about 5000 deaths per year in this country.¹

From 2003 screening has been performed using liquid based cytology (LBC). Meta-analyses have shown LBC to have higher sensitivity, equal specificity and lower rates of inadequate samples.² The percentage of inadequate samples this year fell substantially from consistently over 9% since recording started in 1998 to 4.7%.³

Cervical cancer mortality in England and Wales (in women younger than 35 years) rose three-fold from 1967 to 1987. By 1988, incidence in this age-range was among the highest in the world, despite substantial opportunistic screening. When national screening was started in 1988 this rising trend was reversed.

The 2005 European age-standardised annual incidence rate of cervical cancer in the UK is 8.4 per 100,000 females. Cervical cancer is the second most common cancer after breast cancer in the under 35s, with 671 new cases diagnosed in the UK in 2005.⁴

• First invitation for screening at age 25 in England (20 in rest of UK).
• Routine recall:
  • England: Routine 3 yearly recall between ages 25-49, then 5 yearly recall until aged 65.
  • Scotland: Routine 3 yearly recall from age 20 until aged 60.
  • Wales: Routine 3 yearly recall from age 20 until aged 65.
  • Northern Ireland: 5 year recall recall from age 20 until aged 65 (many GPs run their own recall at an interval of three years).
• Consider offering a smear to patients above the upper age limit who have not been screened since age 50 or have had recent abnormal tests.

• Inflammatory changes usually indicate infection:⁵
  • Mild inflammation
  • Moderate inflammation
  • Severe inflammation
• High risk Human papilloma virus (HPV) types (16, 18, 31, 33) have been found to be present in close to 100% of all cervical cancers. Research has indicated that women with a mild or borderline smear result, who have no evidence of high risk HPV infection are very unlikely to develop cervical cancer.⁶ A Health Technology Assessment review concluded that HPV testing could not currently be recommended for primary screening without further research.⁷ Current evidence does, however, support limited introduction of the test in certain limited situations, such as the management of borderline smears or in older women when regular screening is problematic. HPV is also known as 'wart virus'.
• Actinomyces; a smear may show actinomycete-like organisms (ALO), especially if an IUCD is in situ, but unless there is clinical evidence of pelvic inflammatory disease, they are of no significance.
• Candida; many treatments are available including topical or oral imidazoles.
• Gardnerella; treatment is metronidazole 400-500 mg twice daily for seven days.
• Herpes; antiviral therapy is effective in both initial attacks and recurrences. The licensed drugs are aciclovir, valaciclovir and famciclovir. Oral therapy is required. Topical treatment is inadequate. There is no benefit in combining topical and oral therapy.
• Koilocytosis; this is the presence of koilocytes (cells infected by HPV). They typically have shrivelled nuclei with a halo.⁸ They have a low prognostic value for CIN.⁹
• Trichomonas; metronidazole is treatment of choice.
• Viral inflammation unspecified.